Journ al ofthe Korean Radiol ogical Society 1996 : 35 (2) : 241 - 244 CT Demonstration of the Extensive Extension of the Emphysematous Gangrene ofthe lower Extremity Extending to the Body: A Case Report 1 Hak-Soo lee, M .D. , Hyun-Chul Rhim, M.D., Yong-Soo Kim, M.D ., Soon -Young Song, M.D., Byung-Hee Koh, M.D. , On-Koo Cho, M.D., Kyung-Bin Joo, M.D. Emphysematous gangrene of the lower extremity in a diabetic patient due to minor trauma is being presented. The gas originating from the extremity exten­ ded along the fascial planes into the pelvic cavity, scrotal region, retroperitoneal space, and abdominal wal l. CT demonstrated the pathways of upward extension of emphysematous gangrene. Anatomic pathways of the spread of the d isease a re insertions of the iliopsoas, piriformis and obturator internus muscles, and their fascial investments, and the endopelvic fascia. Anatomic pathways on CTand the role of CTare discussed. Index Words : Abdomen . CT Extremities, radiography Retroperitoneal space , CT Emphysematous gangrene of the lower extremity is pattern in the abdomen_ Pain, redness, and crepitant associated with major trauma, intraabdominal dis­ change in the right thigh were aggravated, however, ease, and non-traumatic metastatic (hematogenous and bullous lesion and bluish discoloration of the thigh spread of gas-forming infection) gas gangrene(1). In developed after admission_ The thigh became more previous articles, the extension of a retroperitoneal in­ swollen , reddish and tender_ flammatory process along the fascial planes to the Plain radiographs of the ri ght lower extremity, hip, lower extremity was discussed(1 , 2). To our knowledge, and simple abdomen taken 10 hrs after admission however, previous investigators have not specifically showed mottled and streaky air of soft tissue in the addressed the possibility of spread of the disease pro­ thigh, pelvis, and large round ballooned scrotum cess to the opposite direction. We recently experienced a case of the emphy­ sematous gangrene of the lower extremity in a diabetic patient with upward extension along the fascial planes into the retroperitoneal space, scrotal region , and ab­ dominal wal l. CASE REPORT A 57-year-old man with diabetes mellitus was hospitalized because of vomiting, fever(37. rc ), and pain in the right thigh due to falling on the floor. On ad­ mission, the right thigh was swollen and tender. Initial plain X-ray on admission showed a normal bowel gas ’ Departmen t ofDiagnostic Rad iology , Col lege 01 Medicine, Hanyang Un iversity Fig . 1. Plain rad iograph take n 10 hrs after th e admi ssion sho ws Rece ived February6 , 1996; Accepted May 30, 1996 mottl ed , streaky ai r of soft tiss ue in th e rig ht hi p jo int an d femur , Add ress reprin t requests to: Hak-Soo Lee , M. D. , Departmen t 01 Diag nostic Rad iology , Coll egeol Medicine , Hanyang University large round bali ooned sc rotum (arrows) , extendin g upward int 。 # 17 , Hae ngdang-dong , Sungdong-ku , Seo ul ,1 33-792 Korea pelvis and retrope riton eum along the right iliopsoas muslce Tel. 82-2-290-9164 Fax. 82-2-291-9866 (arrowheads) • 241 - Journal ofthe Korean Radiological Society 1996 : 35(2) : 241 - 244 extending upward into the pelvis and retroperitoneum External wound culture and aspiration culture from along the right iliopsoas muscle. (Fig. 1.). Duplex subcutaneous tissue was carried out. Fasciotomy was doppler ultrasonographic examination of the right planned, but not performed due to acute renal failure. lower extremity failed due to subcutaneous air. CT scan Twenty-one hours after admission, the patient expired. revealed emphysematous myositis or gas gangrene of Blood and the necrotic tissue culture revealed the right lower extremity, and a small amount of air coagul ase negative staphylococcuS and Clostridium shadow in the right pararectal space. There was a septicum. large amount of air around the right testis of entire scrotum, and medial aspect of the obturator internus DISSCUSSION muscle. Upwardly, gas shadows were also noted ad­ jacent to the greater trochanter, medial aspect of the Emphysematous gangrene of the lower extremity is iliopsoas muscle, anterior abdominal wall , and associated with severe trauma involving penetrating posteromedial aspect of the right psoas muscle(Fig wounds, compound fractures, extensive soft-tissue in­ 2.) jury, and rarely intraabdominal diseases(1). a b c d Fig. 2. a. CT scan at the level of the lesser trochanter of the right femur shows emphysematous gangrene(arrow). Also , The large amount of air around the righttestis of entire scrotum(arrowheads) is visualized b. At three centimeter above a, abnormal gas(arrow) is seen adjacent to the greater trochanter, where the piriformis muscle inserts Gas is also present in right pararectal( long arrow) , and scrotal region (arrowhead) c. Scanning at the level of mid-pelvis , the gas(arrow) is tracking into the interfascial planes between Gluteus maximus and Gluteus medius muscles through the sciatic foramen . The piriformis muscle and gluteal vessels transverse this foramen. Gas is collected in right il iopsoas muscle(arrowhead) and anterior abdominal wal l( long arrows) d. At two centimeter below the left renal hilum , upward extension of the gas is visualized atthe posteromedial aspect(arrowhead) in the right psoas muscle, and poster 이 ateral aspect of the abdominal wall(long arrows) 찌 Hak-Soo Lee, etal: Extensive Extension ofthe EmphysematousGangreneofthe Lower ExtremityExtending to the Body The mode of spread of this gangrene depends on the destructive process and the presence of an underlying anatomical pathways of extrapelvic spaces. Meyers condition or chronic disease such as diabetes mellitus and Goodmann(3) have established the correlation be­ may contribute to the extension of emphysematous tween anatomic pathways and radiologic documen­ gangrene(7). The fascial planes of muscles in the thigh, tation of the extrapelvic spread of disease. They have, pelvic cavity, scrotal region , and retroperitoneum may however, focused on the downward extrapelvic spread be the potential routes or pathways in inflammatory of intrapelvic process. The present case showed the disease. Bidirectional spread of disease originating possible extension of disease from extrapelvic t 。 either in the extrapelvic or intrapelvic and retro­ intrapelvic spaces. Gas gangrene of the right lower ex­ peritoneal space may be possible. Familiarity with the tremity spreads upwardly through the insertions and connection of the fascial plane provides the radiologist fascial investments of the psoas major and iliacus with an explanation of the extension and process of an muscles on the lesser trochanter, of the piriformis inflammatory disease. muscle through the greater foramen on the greater tro­ Diseases arising from the one compartment may first chanter, and of the obturator internus muscle through manifest themselves by signs and symptoms remote the lesser sciatic foramen on the greater trochanter. from their sources of origin. Radiologic evaluation may The parietallayer of the endopelvic fascia covering the be crucial in redirecting the diagnostic and therapeutic intrapelvic portion of the obturator internus and approach as well as in documentating the extent of dis­ piriformis muscles is directly continuous above within ease. CT is a valuable and important method in the as­ the transversalis(abdominal) fascia lining the abdomi­ sessment of the extent of subcutaneous emphysema(1 , nal cavity, the potential routes for the spread ofdisease 2, 3, 7). If emphysematous gangrene in immune su­ upwardly. These pathways are same as those involved ppressed patients is clinically suggested, CT scan in extrapelvic spread, as described by Meyers and should therefore include the lower extremity, pelvis, Goodmann and lower abdomen because of rapid progression and Gas collection in the scrotum and penis is not only a bidirectional extension ofthe gas. necrotizing fascitis confined to the male peritoneum and genitalia, but also an extensioh of emphysematous REFERENCES gangrene. Based on our findings and a knowledge of the anatomy of the male genitalia, the pathway of ex­ 1. Jager GJ , Rijssen HV, Lamers JJH . Sucutaneous emphysema 01 tension of subcutaneous emphysema is same as that the lower extremity 01 abdominal origin. Gasrointest Radio/1990; Fournier’s gangrene(4, 5, 6). The pathway of accumu­ 15 : 253-342 lation of gas in the scrotum can arise from two sources 2. Meshkiov SL , Seltzer SE , Finberg HJ. CT detection 01 in­ (5): one is infection of the lower urinary tract and the traabdominal disease in patients with lower extremity signs and other is perirectal ; it can penetrate Colles’ fascia, and symptoms. J Comput Assist Tomogr 1 982 ; 6(3) : 497 -501 involve the penis and scrotum by direct extension 3. Meyers MA , Goodman KJ. Pathways 01 extrapelvic spread 01 dis­ along the aforementioned fascial planes. Colles’ fascia ease: anatomic-radiologic correlation. AJR 1975 ; 125: 900-909 is not a continuous layer but rather a condensation of fi­ 4. Gaeta M, Volta S, Minuti A, Bartiromo G, Pandollo 1. Fournier’s brous tissue with interstices that allow the spread of a gangrene caused by a perlorated retroperitoneal appendix : CT perirectal process to involve the scrotum and penis(5) demonstration. AJR 1991 ; 156 : 341-342 In our case, two pathways were observed. Gas col­ 5. Spirnak JP , Rensick MZ , Hampel N, Pesky L. Fournier’ s gangrene Reportol20patients. JUro/1984 ;131 :289-291 lection in the ischiorectal space spread first to the 6. Begley MG , Shawker TH ‘ Robertson CN , Bock SN , Wei JD , Latze scrotal fascial planes and then gas collection spread to MT. Fournier’s gangrene : Diagnosis with scrotal US. Radiology Colles’ fascia via the endopelvic and transversalis 1988 ; 169: 387-389 fascia. Gas collection in the pelvic cavity ascends to the 7. Velasquez AR , Yoder IC , Velasquez PA, Papanicolaou N. lmaging infrarenal spaces and then posteromedially to the the effects 01 diabetes on the genitourinary system. RadioGrap­ psoas muscles atthe inferior pole ofthe right kidney.